Summary of Benefits Medicare Advantage Plans South Carolina Abbeville, Cherokee, Greenville, Greenwood, McCormick, Newberry, Pickens, Saluda, Spartanburg and Union Counties H5698 0/0/5-2/3/5 WellCare Emerald Value (HMO) 59 H5698_SC02692_WCM_SOB_ENG CMS Accepted WellCare 204 SC_06_4 SC559SOB6099E_064
Section I - Introduction to Summary of Benefits You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as WellCare Emerald Value (HMO)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what WellCare Emerald Value (HMO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on www.medicare. gov. If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at www.medicare.gov or get a copy by calling -800-MEDICARE (-800-633-4227), 24 hours a day, 7 days a week. TTY users should call -877-486-2048. Sections in this booklet Things to Know About WellCare Emerald Value (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at -877-374-4056, TTY -877-247-6272. Things to Know About WellCare Emerald Value (HMO) Hours of Operation From October to February 4, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Local time. From February 5 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Local time. WellCare Emerald Value (HMO) Phone Numbers and Website If you are a member of this plan, call toll-free -800-36-2273, TTY -877-247-6272. If you are not a member of this plan, call toll-free -877-87-5793, TTY -877-247-6272. Our website: www.wellcare.com/medicare Summary of Benefits
Section I - Introduction to Summary of Benefits Who can join? To join WellCare Emerald Value (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in South Carolina: Abbeville, Cherokee, Greenville, Greenwood, McCormick, Newberry, Pickens, Saluda, Spartanburg, and Union. Which doctors, hospitals, and pharmacies can I use? WellCare Emerald Value (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan's provider and pharmacy directory at our website (www.wellcare.com/ medicare). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, www.wellcare.com/medicare. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on your drug's tier, what stage of the benefit you have reached, and may depend on where you fill your prescription. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Summary of Benefits 2
If you have any questions about this plan s benefits or costs, please contact WellCare for details. Section II - Summary of Benefits For Contract H5698, Plan 59 WellCare Emerald Value (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? $0 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $5,900 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. WellCare (HMO) is a Medicare Advantage organization with a Medicare contract. Enrollment in WellCare (HMO) depends on contract renewal. Covered Medical and Hospital Benefits NOTE: SERVICES WITH A MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. Outpatient Care and Services Acupuncture and Other Not covered Alternative Therapies Ambulance $225 co-pay Summary of Benefits 3
WellCare Emerald Value (HMO) Outpatient Care and Services Chiropractic Care,2 Manipulation of the spine to correct a subluxation (when or more of the bones of your spine move out of position): $20 co-pay Dental Services,2 Diabetes Supplies and Services,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $45 co-pay Preventive dental services: Cleaning (for up to every six months): You pay nothing Dental x-ray(s) (for up to ): You pay nothing Oral exam (for up to every six months): You pay nothing Dental X-rays are covered every 2 to 36 months, depending on type. Diabetes monitoring supplies: 20% of the cost Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 20% of the cost Diabetic supplies and services are limited to specific manufacturers. Diagnostic Tests, Lab and Diagnostic radiology services (such as MRIs, CT scans): $50 Radiology Services, and co-pay X-Rays,2 Diagnostic tests and procedures: $0-50 co-pay, depending on the service Lab services: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): 5% of the cost For most in-network diagnostic procedures/tests, you pay $20. You pay the highest cost share for cardiac stress tests. If you have been diagnosed with COPD, you pay nothing for spirometry testing. Doctor's Office Visits,2 Primary care physician visit: $5 co-pay Summary of Benefits 4
Outpatient Care and Services Doctor's Office Visits,2 Specialist visit: $45 co-pay WellCare Emerald Value (HMO) Durable Medical Equipment (wheelchairs, oxygen, etc.) Emergency Care Foot Care (podiatry services),2 20% of the cost $65 co-pay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $45 co-pay Hearing Services,2 Exam to diagnose and treat hearing and balance issues: $45 co-pay Routine hearing exam (for up to every year): You pay nothing Hearing aid fitting/evaluation (for up to every year): You pay nothing Hearing aid: You pay nothing Our plan pays up to $350 every year for hearing aids. Our plan pays for hearing aid up to $350 every year. Home Health Care,2 Mental Health Care,2 You pay nothing Inpatient visit: Our plan covers up to 90 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $300 co-pay per day for days through 3 Summary of Benefits 5
WellCare Emerald Value (HMO) Outpatient Care and Services Mental Health Care,2 $00 co-pay per day for days 4 through 7 You pay nothing per day for days 8 through 90 Outpatient group therapy visit: $35 co-pay Outpatient individual therapy visit: $40 co-pay Outpatient Rehabilitation,2 Outpatient Substance Abuse,2 Outpatient Surgery,2 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) Renal Dialysis,2 Transportation Urgent Care Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $45-250 co-pay, depending on the service Occupational therapy visit: $40 co-pay Physical therapy and speech and language therapy visit: $40 co-pay For in-network Cardiac rehab services, you pay the lowest cost share for services received in a physician's office and the highest cost share for services received in an outpatient hospital facility. Group therapy visit: $35 co-pay Individual therapy visit: $40 co-pay Ambulatory surgical center: $75 co-pay Outpatient hospital: $250 co-pay Please visit our website to see our list of covered over-the-counter items. Our plan will pay up to $7 every month for the purchase of covered over-the-counter items. Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost 20% of the cost Not covered $55 co-pay Summary of Benefits 6
WellCare Emerald Value (HMO) Outpatient Care and Services Urgent Care If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgent care. See the "Inpatient Hospital Care" section of this booklet for other costs. Vision Services,2 Preventive Care Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-45 co-pay, depending on the service Routine eye exam (for up to every year): You pay nothing Contact lenses (for up to every year): You pay nothing Eyeglasses (frames and lenses) (for up to every year): You pay nothing Eyeglasses frames (for up to every year): You pay nothing Eyeglasses lenses (for up to every year): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $00 every year for eyewear. You pay nothing for in-network Medicare-covered diabetes retinopathy and glaucoma screenings, and you pay the highest copay for all other in-network Medicare-covered eye exams. Our plan covers pair of eyeglasses or contact lenses after cataract surgery each year. You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Summary of Benefits 7
Outpatient Care and Services Preventive Care WellCare Emerald Value (HMO) Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Hospice Inpatient Care Inpatient Hospital Care,2 Inpatient Mental Health Care Skilled Nursing Facility (SNF),2 Prescription Drug Benefits How much do I pay? You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Our plan covers an unlimited number of days for an inpatient hospital stay. $300 co-pay per day for days through 4 $00 co-pay per day for days 5 through 9 You pay nothing per day for days 0 through 90 You pay nothing per day for days 9 and beyond For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 00 days in a SNF. You pay nothing per day for days through 20 $56.50 co-pay per day for days 2 through 00 For Part B drugs such as chemotherapy drugs : 20% of the cost Summary of Benefits 8
WellCare Emerald Value (HMO) Prescription Drug Benefits How much do I pay? Initial Coverage Other Part B drugs : 20% of the cost You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Preferred Retail Cost-Sharing Three-month Tier One-month supply supply Tier (Preferred Generic) $ co-pay $3 co-pay Tier 2 (Non- Preferred Generic) $4 co-pay $42 co-pay Tier 3 (Preferred Brand) $40 co-pay $20 co-pay Tier 4 (Non- Preferred Brand) $90 co-pay $270 co-pay Tier 5 (Specialty Tier) 33% of the cost Not Offered Standard Retail Cost-Sharing Tier One-month supply Three-month supply Tier (Preferred Generic) $9 co-pay $27 co-pay Tier 2 (Non- Preferred Generic) $22 co-pay $66 co-pay Tier 3 (Preferred Brand) $45 co-pay $35 co-pay Tier 4 (Non- Preferred Brand) $95 co-pay $285 co-pay Tier 5 (Specialty Tier) 33% of the cost Not Offered Summary of Benefits 9
WellCare Emerald Value (HMO) Prescription Drug Benefits Initial Coverage Preferred Mail Order Cost-Sharing Tier One-month supply Three-month supply Tier (Preferred Generic) $ co-pay $0 Tier 2 (Non- Preferred Generic) $4 co-pay $35 co-pay Tier 3 (Preferred Brand) $40 co-pay $00 co-pay Tier 4 (Non- Preferred Brand) $90 co-pay $225 co-pay Tier 5 (Specialty Tier) 33% of the cost Not Offered Standard Mail Order Cost-Sharing Tier One-month supply Three-month supply Tier (Preferred Generic) $9 co-pay $27 co-pay Tier 2 (Non- Preferred Generic) $22 co-pay $66 co-pay Tier 3 (Preferred Brand) $45 co-pay $35 co-pay Tier 4 (Non- Preferred Brand) $95 co-pay $285 co-pay Tier 5 (Specialty Tier) 33% of the cost Not Offered If you reside in a long-term care facility, you pay the Standard Retail Cost-Sharing. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Summary of Benefits 0
WellCare Emerald Value (HMO) Prescription Drug Benefits Coverage Gap Catastrophic Coverage Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost, or $2.65 co-pay for generic (including brand drugs treated as generic) and a $6.60 co-payment for all other drugs. Summary of Benefits
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www.wellcare.com/medicare 6099